Independent validation of the ICU requirement score in a cohort of acutely poisoned adults

Objective: To independently validate the predictive value of the intensive care requirement score (IRS) in unselected poisoned patients.

Design: Retrospective chart review.

Patients and methods: Five hundred and seventeen out of 585 admissions for acute intoxications could be analyzed. Eleven were excluded for a condition already requiring intensive care unit (ICU) support at admission (e.g., preclinical intubation). A further 57 admissions were excluded due to missing data. The IRS was calculated using a point-scoring system including age, Glasgow Coma Scale, heart rate, type of intoxication, and preexisting conditions. It was then compared to a composite endpoint indicating an ICU requirement (death in hospital, vasopressors, need for ventilation). The endpoint and the point-scoring system were identical to the original publication of the score.

Results and conclusion: Twenty-three out of 517 patients had a complicated clinical course as defined by meeting the endpoint definition. Twenty-one out of 23 complicated courses had a positive IRS (defined as greater or equal 6 points), as compared to 255/494 patients with an uncomplicated clinical course (p?相似文献   

Embolic protection devices for carotid artery stenting: better results than stenting without protection?

AIMS: Carotid artery stenting (CAS) for carotid artery stenoses has become an alternative to carotid endarterectomy. However, CAS itself can cause cerebral ischaemic events. Embolic protection devices (PD) promise to reduce the incidence of these events. METHODS AND RESULTS: From July 1996 to March 2003, 1483 patients from 26 hospitals were included in the prospective CAS Registry of the ALKK study group. A PD was used in 668 of 1483 patients (45%). The use of a PD has grown rapidly over the years and reached 100% in 2003. Patients treated with a PD had prior carotid artery dilatation more often (3.5% versus 1%, p < 0.001), a prior myocardial infarction (34% versus 27.4%, p = 0.007) and a history of arterial hypertension (89.9% versus 78.6%, p = 0.007) compared to patients treated without a PD. A thrombus was more often visible in patients treated under distal protection (16.5% versus 8%, p < 0.001). The use of a PD led to a 10-min longer intervention (45 min versus 35 min median, p < 0.001). Patients treated with a PD had a lower rate of ipsilateral stroke (1.7% versus 4.1%, p = 0.007) and a lower rate of all non-fatal strokes and all deaths (2.1% versus 4.9%, p = 0.004) during the hospital stay. This was confirmed by multiple logistic regression analysis (adjusted OR = 0.45, 95% CI: 0.23-0.91, p = 0.026). A similar reduction could be found for symptomatic as well as asymptomatic carotid artery stenoses. CONCLUSION: Since 1996 there has been a steady increase in the use of PDs for CAS, with a 100% use in 2003. The use of a PD may lower the rate of ipsilateral strokes during CAS.     

Impact of ramipril versus other angiotensin-converting enzyme inhibitors on outcome of unselected patients with ST-elevation acute myocardial infarction

We examined the impact of treatment with ramipril versus other angiotensin-converting enzyme (ACE) inhibitors on clinical outcome in unselected patients of the prospective multicenter registry Maximal Individual Therapy of Acute Myocardial Infarction PLUS registry (MITRA PLUS). Of 14,608 consecutive patients with ST-elevation acute myocardial infarction, 4.7% received acute therapy with ramipril, 39.0% received other ACE inhibitor therapy, and 56.3% received no ACE inhibitor therapy. In a multivariate analysis, the treatment with ramipril compared with the treatment without ACE inhibitors was associated with a significantly lower hospital mortality and a lower rate of nonfatal major adverse coronary and cerebrovascular events. Compared with other generic ACE inhibitors, ramipril therapy was independently associated with a significantly lower hospital mortality (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.32 to 0.90) and a lower rate of nonfatal major adverse coronary and cerebrovascular events (OR 0.65, 95% CI 0.46 to 0.93), but not with a lower rate of heart failure at discharge (OR 0.79, 95% CI 0.50 to 1.27).     

Expression profile of the telomeric complex discriminates between benign and malignant pheochromocytoma

Telomerase, a ribonucleoprotein complex that includes the telomerase RNA component, the telomerase-associated protein (TP1), the telomerase catalytic subunit (hTERT), and the heat shock protein 90 (HSP90), is closely related to the malignant potential of human tumors. In pheochromocytomas (PC) it is very difficult to predict malignant potential by conventional histology or immunohistochemical and molecular markers. To test whether the expression of telomerase subunits is reflected in the malignant transition of PCs, we determined their mRNA and/or protein expression in 28 benign and nine malignant PCs and compared the results with telomerase activity. RT-PCR analysis revealed that TP1 was ubiquitously expressed. The telomerase RNA component was found in all malignant (100%) and in 13 of 28 (46%) benign PCs. In contrast, hTERT was clearly associated with aggressive biological behavior. All of the malignant (100%), but only two of 28 benign (7%) PCs expressed hTERT. HSP90 was increased in malignant PCs, but was also expressed at a lower level in benign tumors. High telomerase activity was measurable in hTERT-positive tissues only. Our data indicate that hTERT, HSP90, and telomerase activity are up-regulated in malignant cells of the adrenal medulla. The common expression of hTERT and telomerase activity thus represents an additional prognostic marker that may identify more aggressive tumors.     

Die dorsoposteriore extraperitoneale Pelviskopie (DEP) Rektum erhaltende mesorektale Resektion beim T1-High-Risk-Rektumkarzinom

Zusammenfassung Hintergrund: Die lokale Rektum erhaltende Resektion des Low-Risk-T1-Rektumkarzinoms ist heute ein als Standard akzeptiertes Verfahren. Bei den High-Risk-T1-Tumoren ist bei nicht bekanntem Lymphknotenstatus eine Rektumresektion zu fordern. Mit der dorsoposterioren extraperitonealen Pelviskopie (DEP) wurde eine Methode entwickelt, mit der das Mesorektum in minimalinvasiver Technik unter Erhaltung des Rektums reseziert werden kann, um so auch das nodale Stadium zu diagnostizieren. Patienten und Methodik: Bei bisher zehn Patienten mit High-Risk-T1-Rektumkarzinom wurde nach transanaler R0-Resektion und konventionellem Staging mit CT, Abdomensonographie und transanaler Sonographie in der Regel zweizeitig eine DEP durchgeführt. Die Eingriffe erfolgten in Allgemeinnarkose in Bauchhängelage (Götze-Lagerung). Das Spatium retrorectale wurde mit einem Dilatationsballonsystem von perineal aufgedehnt, ein Pneumoextraperitoneum angelegt und das Mesorektum über drei Ports reseziert. Ergebnisse: Es gelang problemlos und unter Sicht, das Spatium retrorectale zu dilatieren. Der entstandene Arbeitsraum konnte unter hervorragenden Sichtverhältnissen bis zum Promontorium sacri erweitert werden. Das Mesorektum wurde im Sinne einer Staging-Operation vollständig reseziert. Bei der histologische Aufarbeitung der Resektate fanden sich zwischen vier und 20 Lymphknoten. Bei einer Patientin bestand histologisch eine Mikrometastasierung. Im Verlauf zeigte sich bei dem einmalig durchgeführten, einzeitigen Vorgehen eine Wundheilungsstörung im Bereich der Vollwandexzision mit Ausbildung einer rektrovaginalen Fistel. Bei einer weiteren Patientin fanden sich bei der 6 Wochen postoperativ durchgeführten Analmanometrie Zeichen einer Inertia recti. Schlussfolgerung: Mit keiner diagnostischen Maßnahme außer der Histologie lassen sich befallene Lymphknoten ausschließen oder beweisen. Bei der mesorektalen Resektion mittels DEP ist ein adäquates Lymphknoten-Staging erzielbar. Das Rektum erhaltende Vorgehen kann auch auf die Gruppe der High-Risk-T1-Rektumkarzinomen ausgedehnt werden und eine differenziertere Therapieplanung ermöglichen. Abstract Background: Local resection of low-risk T1 carcinoma of the rectum is an accepted standard of treatment. In high-risk T1 tumors a standard resection should be considered due to the possibility of lymph node metastasis. The dorso-posterior extraperitoneal pelviscopy (DEP) is a method to explore and dissect the mesorectum as a staging procedure. Patients and Methods: We describe the results of ten patients with high-risk T1 rectal cancer in whom, following transanal R0 resection and conventional staging (CT scan, transanal endosonography and abdominal sonography) DEP was performed. The operation was carried out in general anesthesia, the patient in prone jack-knife position. The retrorectal space was dilated with a balloon through a dorso-posterior approach. The extraperitoneal pelvic structures were dissected with a three-port technique and CO₂ insufflation. Results: The procedures were performed without technical difficulty. With this method we could extract between four and 20 lymph nodes. In one patient micrometastases where detected. In the only one-stage procedure the patient developed an insufficiency of the transanal suture and a rectovaginal fistula. In a second patient we found an inertia recti 6 weeks postoperatively. Conclusion: A positive lymph node stage can only be diagnosed histologically. DEP is a method that aspires to achieve histological lymph node staging following local resection of high-risk T1 tumors, so that rectum-sparing treatment can be supported. Indications for rectum-sparing surgery could possibly also be extended to high-risk T1 tumors with this method.